The difference between getting off drugs and staying off drugs, a wise man once told us, is the difference between a wedding and a happy marriage.
“The wedding is a big deal, but it has nothing to do with a happy marriage,” Walter Ling, professor of psychiatry and founding director of the Integrated Substance Abuse Programs at UCLA, observed when we began tracking tragedy in the addiction treatment industry. “Right now, our entire treatment system is targeted to the wedding.”
Ling’s research — and the work of many others — has shown the effectiveness of medications in battling drug addiction. California has been prodding its 1,800 licensed treatment facilities to embrace these medications for years — drugs that bind to the brain’s opioid receptors and foil opioid highs, helping people manage cravings, prevent overdoses and, generally, pave the way for a happy marriage.
But a tremendous chunk of treatment facilities in California — 41% — resist. They didn’t provide any “pharmacotherapy services” for their patients at all, despite skyrocketing overdose and death rates, according to data compiled by the Substance Abuse and Mental Health Services Administration.
Just 22% of California’s outpatient facilities — where most treatment happens — offered methadone, buprenorphine or naltrexone treatment. These are the gold standards for managing opioid addiction.
And only 59% of programs transitioning people back to their regular lives offered overdose education and Naloxone, a drug that can reverse opioid overdose and practically bring people back from the dead.
Why? It’s a vestige of the abstinence-only, “Don’t replace one drug with another” philosophy that drives so many 12-step-centric programs in the state — particularly in Orange County, ground zero for California’s treatment industry — and it’s an outrage. Enter now researchers from The Pew Charitable Trusts’ substance use prevention and treatment initiative, pushing states like California to adopt very specific data-tracking that can illuminate what works and what doesn’t — and save lives.
Follow the numbers
California and many states have public-facing dashboards tracking overdose deaths, emergency room visits, hospitalizations and opioid prescriptions. “But far too few track a full range of metrics, including how many people are diagnosed with OUD (Opioid Use Disorder), the number of providers available to treat them, use of FDA-approved medications or treatment retention and outcomes,” Pew said.
You can’t manage what you can’t measure, the old saying goes, but officials can’t agree on what should be measured. So Pew convened its own panel of experts, and it settled on key measurements in the life cycle of a chronic disease, “cascading” from initial diagnosis to final outcome. This approach has been used worldwide to manage hepatitis C, HIV, diabetes and other chronic diseases, and it can be used here, they said.
What should be tracked? Try the percentage of people with documented OUD diagnoses. How many were assessed using a standardized screening tool. Who gets medication as part of the treatment regimen. The number of providers and treatment programs that can provide medication. The percentage who use medication for at least six months; who receive follow-up care for substance use or overdose within seven and 30 days after visiting an emergency department for substance-related issues; and several other pertinent things.
“I hope to see states across the country adopt this set of measures, and start understanding what’s really happening in treatment,” said Pew’s Frances McGaffey. It should then be used to implement the policies that work best.
Addiction treatment is a $42 billion business in the U.S., much of it paid for by the government and private insurers who, last time we checked, got their money from you and me. Orange and Los Angeles counties are home to more than half the licensed or credentialed addiction treatment programs in the state. It sure would be nice to spend that money where it works best. With more than 100,000 overdose deaths in a single year, something is clearly awry.
In Orange County, 503 people died after opioid overdoses, and 1,181 wound up at the emergency room, according to 2020 data. There were more than 1 million opioid prescriptions, in a county of 3 million people.
Steps forward
State officials weren’t able to share their thoughts on Pew’s framework by deadline, but Dr. David Kan, an addiction medicine specialist and past president of the California Society of Addiction Medicine, thinks they’d be quite useful.
“In general they have the right metrics, from diagnosis to treatment, soup to nuts,” Kan said, speaking just for himself.
There are things he’d like to see added, though — including methadone participation and Naloxone distribution. Naloxone isn’t treatment, but prevention, he said — the drug is the most proven intervention in fatal overdose, with medication-assisted treatment (buprenorphine, etc.) coming in second. Knowing who gets Naloxone and how it impacts survival would be most valuable: Among people who survive an overdose, almost 10% die within a year, Kan said.
California has more than 1,700 addiction treatment facilities treating more than 70,000 clients — including more than 2,000 children, according to SAMHSA data. When we first began reporting on the industry in 2017, there were just 1,000 doctors with the federal waiver required to prescribe buprenorphine. Today, there are more than 5,000.
“From 30,000 feet, I’d say we’re doing better from a treatment standpoint,” Kan said.
But we clearly have a way to go before we hit the “happy marriage” stage.
Source: Orange County Register
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